| DIET INFORMATION SHEET Please answer as correctly as you can, thank you. 1. -- Is it easy for you to get up on a average morning? Do you feel awake and energized? YES -- NO _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 2. -- Do you eat breakfast in the morning? If YES what does it usually contain? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ -- If NO, what is the reason for doing so? _______________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 3. -- Do you usually eat lunch? YES -- NO ? And if you do are you making it at home or conveniently order lunch from a restaurant near home/work? ________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ What do you normally eat over lunch? ________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ If you do not have the habit of eating lunch please tell me why ______________________________ _______________________________________________________________________________ _______________________________________________________________________________ 4. -- Do you find yourself snacking allot during the day? YES -- NO If YES what kind of snacks are you habitually eating? _____________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 5. -- Do you drink allot of water throughout the day? YES -- NO, and what other drinks you drink regularly? _______________________________________________________________________________ _______________________________________________________________________________ 6. -- Around what time do you usually have dinner? What is the ratio between cooking at home versus take-outs? _______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 7.-- What kind of meals do you prepare for dinner time? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 8. -- Do you finish with a dessert? If YES what kind of desserts or drinks? _______________________________________________________________________________ _______________________________________________________________________________ 9. -- Do you find yourself snacking in between dinner and bed time? If YES on what? _______________________________________________________________________________ _______________________________________________________________________________ 10. -- Do you drink alcohol? YES -- NO, If you do what is your average amount of alcohol intake a week? And what type of drinks you enjoy? _______________________________________________________________________________ _______________________________________________________________________________ 11. -- Around what time you usually find yourself going to bed? And do you sleep a good 6-8 hours or are your nights restless? __________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 12. -- Do you have any known food allergies and if so have you ever been tested for them? _______________________________________________________________________________ ________________________________________________________________________________ _______________________________________________________________________________ 13. -- Are you active as in walking, running or a member of a gym? And how often do you exercise? _______________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 14. -- Do you enjoy the consumption of fruits and vegetables? And how many portions of them you consume on average? ____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 15. -- Do you take supplements of any kind? If YES , which type and how often? ________________________________________________________________________________ ________________________________________________________________________________ 16. -- Did you ever undertake a cleanse or a fast? If you did what type and for how long? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 17. -- Did you ever diet before? If you did what type of diets did you try out? And how did you feel and why did it not work out? ___________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 18. -- Are you suffering from any illnesses at the moment and if so are you under professional care and taking medication? ______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 19. -- Do you smoke cigarettes? YES -- NO 20. -- Do you drink coffee? YES -- NO -- Your name please ___________________________________ -- Address ___________________________________ -- Telephone ___________________________________ Additional comments -- ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Thank you very much |
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